With the significant rise in methicillin-resistant Staphylococcus aureus (MRSA) infections, a small rise in the number of cases of Clostridium difficile colitis appears to be an unfortunate but unpreventable consequence of using the few effective antibiotics remaining that can be prescribed in the outpatient setting.
A 2-year-old boy was brought to the emergency department by his mother after he slipped and fell in the bathtub. The boy's father, who had been bathing the child when the injury occurred, reported that he had briefly turned his back while the child was attempting to drink from the hook-shaped faucet. The child had jerked his head upward when he fell, thus causing the sharp edge of the faucet tip to lodge in the soft floor of the mouth beneath the tongue. The father, in desperation, wrenched the faucet from its base and then was able to remove the tip from the child's mouth. During the removal process, the child reached up and also cut his finger on the sharp edge of the faucet.
For several days, a 38-year-old man has had an increasingly painful swelling behind the right knee. He runs several times a week. He has hypertension but no history of trauma or periods of inactivity, and no chest discomfort or shortness of breath. He drinks alcohol occasionally but does not use tobacco or illegal drugs.
A 40-year-old Hispanic homemaker is admitted with a 3-week history of high fever, chest pain, and a dry, irritating cough. Her illness began insidiously with increasing right upper chest pain that is sharp, pleuritic, and rates a 6 on a pain scale of 1 to 10. The pain is associated with temperatures of up to 38.8°C (102°F) and chills, rigors, and profuse sweating that increase in the evening. Worsening dyspnea has been accompanied by a drop in effort tolerance.
US researchers recently reported initial phase 1 results from 2 vaccine candidates that successfully produced immune responses in healthy uninfected adults (Gibian JJ. United Press International. November 16, 2006). Eventually, the approach may be used to protect against HIV infection. Barney Graham of the NIH Vaccine Research Center and colleagues performed the tests (Graham BS, Koup RA, Roderer M, et al. J Infect Dis. 2006;194:1650-1660; Catanzaro AT, Koup RA, Roderer M, et al. J Infect Dis. 2006;194:1638-1649).
A 68-year-old woman with type 2 diabetes mellitus presented with a sore throat of 3 days' duration and progressively worsening dysphagia to both solids and liquids, including her own saliva. She denied consumption of steak or fish with bones. Attempts to swallow caused her to grimace. Her voice was normal and her airway was clear, but tenderness was noted when the larynx was moved side to side.
A 41-year-old woman presented to the emergency department with abdominal pain and vomiting of 1 week's duration. She had a history of surgery for bowel malrotation at age 11 days.
Avian influenza primarily affects wild birds and domesticated poultry. Humans acquire avian influenza viruses chiefly through direct contact of the mucous membranes with secretions or excreta from infected birds or contaminated poultry products. The upper respiratory tract and conjunctivae appear to be the main portals of entry. Influenza pandemics occur when new virus subtypes emerge and become readily transmissible among humans. On average, pandemics occur about 3 or 4 times per century. Avian influenza is not a pandemic influenza. It is not easily transmitted among humans, and it has not been found in the United States. Therefore, at present, the risk to persons in this country is considered low.
An agitated and confused 51-year-old man is brought to the emergency departmentby his family and friends. Recently, he had been drinking heavilyand smoking cocaine. He stopped using alcohol and cocaine 2 days earlier,after he began to vomit.
A 58-year-old man presents with exertionaldyspnea of 6 weeks’ duration, adry cough for 2 weeks, and decreasedappetite. He denies fever, chills, sputumproduction, hemoptysis, cigarette smoking,and significant weight loss. Thepatient, a retired electrician, was exposedto asbestos 20 years earlier.
A pruritic rash under the left breast has bothered a 67-year-old woman forthe past month. She takes an antihypertensive and is otherwise healthy.
For 3 months, a 66-year-old retired man has had increasingweakness of the lower legs with stiffness,tingling, and numbness; worsening ataxia; anergia; andexertional dyspnea of insidious onset. He has lost 8 lb,and his appetite is poor. He denies fever, cough, chest orabdominal pain, paroxysmal nocturnal dyspnea, orthopnea,ankle swelling, bleeding disorders, hematemesis,melena, headache, vision problems, sciatica, joint pain,bladder or bowel dysfunction, and GI symptoms. He hasnocturia attributable to benign prostatic hypertrophy.
A 52-year-old woman presents with a3-month history of a tender, erosivedermatitis on the nipples and in thevulvar/perineal region. Can youidentify these lesions?
For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.
Historically, tuberculosis (TB) was the most commoncause of hemoptysis. Classic operas, such asLa Traviata and La Bohème, featured dramatic scenes ofhemoptysis, often with the heroine dying following episodesof deep passion and coughing.
Q:My patient has an elevated hemoglobin concentration and hematocrit; however, the reticulocyte count, ferritin level, results of hemoglobin electrophoresis, and total iron-binding capacity are normal. What is the next step after common causes of an elevated hemoglobin concentration and hematocrit, such as chronic obstructive pulmonary disease, have been ruled out?
A 32-year-old man complains ofknee pain that resulted when he felland twisted his right knee skiing theday before. He suffered other minorcontusions from the fall, but none ofthese required medical attention. Heis otherwise in good health and hasno relevant medical history.
Quinolones are commonlyused to treat a widevariety of infectious diseases,such as community-acquired pneumoniaand urinary tract infections. Somequinolones are also given as prophylaxisfor spontaneous bacterial peritonitis.These popular antimicrobial agents areassociated with several clinically significantdrug interactions, which can beclassified into 2 major categories1-3:
A 56-year-old African American man presents with a painful “raw” lip that hasgradually developed during the summer. Physical examination reveals a geographic,superficial erosion; notably, the erosion is surrounded by hypopigmentedand, most distally, hyperpigmented rings. The patient believes that exposureto sunlight has aggravated the condition.
For several days, a 35-year-old woman has had a swollen, painfulfinger. She is otherwise healthy and has no significant medical history.
For 3 months, a 41-year-old womanhas had a pruritic acneiform eruptionon the lateral aspects of the neck andthe left side of the face. She is otherwisehealthy and takes no medication.
A 16-year-old boy presents for evaluation of various lesionsthat have appeared on his extremities since he joined thewrestling team 2 months earlier. He is otherwise healthyand takes no medications.
A thin 26-year-old man has hadintermittent diarrhea with abdominalpain, nausea, vomiting, and occasionalepisodes of hematochezia for8 months. He also complains of weaknessand fatigue and has lost 4.5 kg(10 lb) in the past year. The patientis homosexual and admits to havinghad unprotected sexual intercourse.He denies any significant travelhistory.
A 51-year-old woman has had a progressiverash on the trunk, proximalarms, and legs for 2 weeks, followingthe latest round of chemotherapy forbreast cancer. Around the time thatthe rash erupted, she was also takinglevofloxacin for a productive cough.Cutaneous lupus erythematosus wasdiagnosed years ago, but she hasbeen disease-free for the past 5 years.Chemotherapy is being withheldpending diagnosis of the rash.
